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Examinations
LEADING ARTICLES
385
subject. They now have no further hurdle for eighteen months and often for two and a half years. Then they prepare for the culminating marathon of the finals," which further distorts their understanding by its division into three or more subjects. Few people with experience of students other
at least
THE LONDON:
LANCET
SATURDAY, AUGUST 25, rsss
"
"
Examinations By the Medical Act of 1858 the General Medical was given statutory authority to ensure that registrable medical qualifications carry the knowledge and skill necessary for the efficient conduct of medical practice. A qualifying examination was therefore established as the final test of the candidate’s competence to practise independently (and often in comparative isolation); and by the Medical Act of 1888 he had to qualify in three subjects-medicine, surgery, and midwifery. Since that time there have been enormous changes in general and hospital practice ; and the conditions for registration have been changed too, notably by the Medical Act of 1950, which requires twelve months of house appointments under supervision. Yet the general form of the final examination is the same as it was sixty-eight years ago. There are differences in detail between the examinations held by the 27 licensing bodies, but, in all of them, equal importance is still given to the three major
Council
"
"
are now almost exclusively a test Finals of factual knowledge, and are a poor guide to a candidate’s true worth. Even in the practical part of the examination, the time available and the conditions under which it is carried out allow only a cursory assessment of methods of observation and thought. Of the written papers, PICKERINGhas lately spoken severely : they -" allow no choice of
parts.
question, and they seem designed not to test a student’s capacity to discriminate but his capacity to reproduce material learned from the pages of textbooks or the notes of lectures. The kind of question which is still current in the final examinations for university degrees in medicine is a question such as,Describe the symptoms, signs, complications, and treatment of ulcerative colitis.’ What a comment on six years of university education ! The influence exerted on the medical student by his examinations far exceeds any other that he may meet, and this influence directs him to gain factual knowledge. From the age of 11he has lived under the threat of examinations, and as one follows another he usually comes to accept the view that the acquisition of facts is the primary purpose of study. Moreover, the only method of learning of which he has any experience is often that of committing to memory. There is little doubt that many students spend their lives alternately engaging in and resting from frantic outbursts of blind memorisation. For many, the longest period of rest coincides with the first half of their clinical studies. They have by that time passed the 1st M.B., which (unlike their personal qualities as judged by a selection committee) is the essential requirement for entry into medicine. They have also passed the strict filter of the 2nd M.B.: and many of them have shown such devotion to the bare facts of the examination subjects that they can have achieved little understanding of them and none at all of any "
1.
Pickering, G. W.
Brit. med. J. July 21, 1956, p. 115.
I’m sure I’ve failed have not heard such remarks as Medicine because my answer to that question on dehydration was just pure Surgery." Unhappily, this process of fragmentation is evident throughout the whole medical curriculum. Because the entire examination system has remained virtually unchanged, all additions to knowledge, all the fresh alignments of thought and practice, and all the new combinations between medicine and the other sciences have to be presented to the student in the same old watertight compartments created by the examinations of long ago. The 2nd M.B., in its present form, confines the study of preclinical sciences and bars their integration with clinical work ; and the qualifying examination as effectively prevents continuity between undergraduate and postgraduate study. There can be little doubt, therefore, that our present examinations exert an influence on medical education as unsound as it is powerful. It is unsound because it leads the student to learn facts in isolated blocksand by the worst methods. As LANDELLS puts it,2Z our examinations misdirect the student’s effort because they demand so many parlour-tricks. Their influence is powerful because they are almost the only method of assessment, and therefore upon them depends the chance to enter and stay in a medical school. Financial aid is very often given largely on examination results, and this puts an added emphasis on the examination as the paramount incentive in the minds of the many grant-aided students. The absence of other methods of assessment, and particularly of close personal observation of the individual student by his teachers, ensures the dominance of the examination system over student and curriculum and thereby is partly responsible for the unhealthy effects of that dominance. Improvement in the actual examinations and better timing of them cannot alone put matters right, but until these things have been done there will be little chance of any other improvement. This is the point at which the vicious circle of too many students seeking too much of an ever-increasing amount of factual knowledge must be broken. One of the main reasons why the system, and particularly the qualifying examination, has never been changed is that many people have regarded it as a reasonably accurate form of assessment. Overthe past few years, however, the evidence of its inaccuracy has mounted, and in this issue Professor BULL adds to it by describing the results of his carefulinvestigation of the final examination in medicine at the Queen’s University of Belfast. His findings show clearly that " there is a considerable element of error in the marking of long essay questions, but this error diminishes progressively as the questions are shorttened." Such inquiries are valuable because they provide conclusive objective evidence for what has been obvious for a long time-namely, that there is a large element of chance in these examinations. The best students sometimes fail, and (what is more dangerous) the worst students sometimes pass. It is 2.
Landells, J. W.
Lancet, Aug. 4, 1956, p. 246.
386 its inaccuracy as a method of assessment, coupled with the premium it puts on factual knowledge, that makes the final examination such an unreliable way of maintaining standards. The General Medical Council’s view, put to the Goodenough committee,3 was that the standard of professional practice essential for the safety of the public " depends much more on the efficiency of clinical and other teaching in medical schools than on any control which the Council can exercise by inspecting qualifying examinations." On the other hand, LANDELLS remarks2 that present-day examinations make no use of a splendid opportunity to investigate the teaching which is being given : " they may be an examination of the students but they are not, as they should be, an examination of his teachers." The ability of the final examination to maintain standards is reflected in what happens to those who fail. Every year, despite the recent fall in the failure-rate in the London M.B., hundreds of medical students fail their finals. The vast majority of them pass six or twelve months later. In this period by which their education is extended, it is unlikely that much is done to increase the safeguards for the public. After failure, many students widen their clinical experience hardly at all and engage in more frantic memorisation. Some turn to the crammer, whose successes are based on intensive drilling in examination technique-a bitter mock of the examination and the whole system of medical education. In fact, the experience of the extra six months often lowers the student’s standards and his morale ; and this delay in qualification certainly proves baffling and expensive to the authoritythat is helping to pay his way. Thus, failure in the final examination seems to do little to ensure the qualification of a better doctor six months or so later ; but perhaps this is offset by the fact that students actually learn as the result of It is true that some do so, but in examinations. fouAo6n medical schools students still face external final examinations, and those who fail are as a rule completely in the dark about why. There is no objective evidence that external examinations make for more accurate testing and it is hard to believe that they help to maintain a uniform standard. If they do, then logically the sooner a national external qualifying examination is instituted the better. Meanwhile, failure-rates of up to 50% continue in some external finals : those who fail do not know why ; the examiners know very little of the candidates’ records of work ; and the teachers are deprived of the help which this assessment of their students could give. A corollary to the high failure-rate is that many students take, as an insurance, the Conjoint diploma, piece by piece, during their last clinical year. ELLIS4 has latelv condemned this course, because it " not only adds to the financial strain, but also interferes seriously with the third year of clinical training ; for the idea that students take these extra examinations merely for practice, without specific preparation and without undue concern, is, in my experience, largely a myth. There is no more lamentable facet of medical education in this country than the double external qualifying examination." 3. Report of Interdepartmental Committee H.M. Stationery Office, 1944. 4. Ellis, J. R. Lancet, 1956, i, 816.
on
Medical Schools.
We
few reasons, therefore, for retaining the examination system. Fortunately it should
can see
present
not be hard to
provide a better one. Changes must be directed along two lines. Firstly, the whole system must be closely integrated to the student’s developing knowledge and practical ability during his training. Only thus can the examination be the servant of education rather than its master ; and to be really effective the results of all the earlier examinations should be discussed with each student. So far as clinical work is concerned, the final examination should be one in the general principles of clinical medicine, but there should also be special tests in the essentials of diagnosis and the management of emergencies in medicine, surgery, and obstetrics, which could best be taken at the end of each relevant period of clinical work. Secondly, the examinations themselves should be made more accurate as a measure of a student’s attainments. Professor BULL recommends that more use should be made of the multiple-choice technique of examining, which eliminates marking error." This form of paper has been much used in the United States,5where it has proved effective as a means of comparing the knowledge acquired by students of different schools, and therefore, as a means of maintaining standards of knowledge. It is, of course, a method applicable to fact rather than to powers of discrimination, for which other tests must be applied. As Professor BULL says, it should not be opposed on the grounds that it " will cause the students to lose what little ability they have to write English." The hurried answers to the present essay-type questions can hardly be considered as serious practice in writing English prose. LANDELLS has suggested that a brief viva will divide those who are clearly competent from those who are doubtful, and that this lesser group could then sit a longer written examination. Changes like these, combined with better coördination of examinations and studies, would make things less exacting for both student and examiner and should give a more accurate picture of a student’s capacity to learn, while retaining the value of examinations as an incentive to work. They will not, however, give much idea of the candidate’s powers of observation and thought. These can be effectively measured only by close observation of the student at work - ideally, when practising under supervision with some responsibility. No such opportunity now arises except during the preregistration year, after the final examination, so that a big change in the present curriculums is necessary-and many would add urgently so.6 The recent pleas for elasticity in the curriculum made by the Royal College of Physicians and others are peculiarly relevant. PICKERING1 has said that " any attempt at defining a medical undergraduate course "
is
a compromise, and a purely arbitrary There are many ways to Rome. We shall never find out the best way so long as all pilgrims are forced to take the same path." The curriculum must be relaxed before other paths can be tried. Standards could be as effectively maintained as they are at present if the General Medical Council were to adopt the suggestion of control by inspection of medical schools, and if the " Council’s inspection of a medical
necessarily
one.
Sinclair, D. C. Ibid, 1953, ii, 947. 6. See Ibid, 1955, ii, 425 ; and also proposals of the Royal College of Physicians of London, Ibid, 1956, i, 437. 5.
387
school’s examinations should henceforward be part of their inspection of the medical school itself." 7 In this way a school could make full use of progressive assessment by the teacher’s own observations, which is now successfully used in the best American universities--often with very little in the way of supplementary examinations. It is notable that, under these conditions, students work harder as well as more profitably ; for the weaker incentive from fear of examinations is more than balanced by the stronger spur from increased interest in their work. It must be borne in mind that some American schools have demonstrated the unfortunate results of relying on innumerable tests. This is important because the impression has grown up in this country that the examination is the only assessment and the only incentive : Examinations are the only effective way to make the average student take a subject seriously."8 There can be but poor training while such views dictate policy. When we have got beyond this outlook, education in its true sense should be possible, and it may even be that the final examination could include an honours paper, with a choice of questions enabling the candidate to show his powers of reasoning and discrimination. Meanwhile, we must remember that the results of our present system can be little improved even by the most enlightened examiners. So long as there is no limit to the factual knowledge covered by the examination, the strongest impetus in medical education will not bewhat the examiners know they are seeking but what the students believe the examiners are seeking. "
Annotations MEDICAL ETHICS EXPLAINED IN this country, contrary to popular belief, only a minority of doctors have taken the Hippocratic Oath or have given any similar pledge. But, especially abroad, many universities now ask for an explicit affirmation ; and at Witwatersrand, for example, medical students entering their second year must subscribe to a declaration of professional secrecy. The student (or his senior) who wants a guide to medical ethics could not do better than read the small book in which Prof. G. A. Elliott of that university and recently set out the ethical codes of the world, explained how they apply in everyday work.99 His guide to medical ethics has, as he says, a South African flavour ; but its subject is universal, and so is the wisdom he offers. Effectively, he makes once more the fundamental point that the main purpose of ethics is to ensure the patient’s welfare (regardless of the doctor’s convenience), and that the patient’s welfare demands the right relationship not only between doctor and patient but also between doctor and doctor. " A doctor ought to behave to his colleagues as he would have them behave to him," says the International Code of Medical Ethics, and so should a student. Professor Elliott’s own philosophy is illustrated by his concluding remark that, even though we may fall far short of our ideal of service, "to act in accordance with the traditional ethics of medical practice is its own reward." 7. A Report of Medical Teaching Committee of the Royal College of Physicians of London. See Lancet, 1955, ii, 132. 8. Curran, D. Brit. med. J. 1955, ii, 515. 9. Medical Ethics. By G. A. ELLIOTT, professor of medicine in the University of Witwatersrand. Johannesburg : Witwatersrand University Press. 1954. Pp. 55.
EXPERIMENTS ON STUDENTS THE big advances in chemical pharmacology and the enthusiasm for new antibiotics mean that more and more drugs have to be tried and more and more human beings have to be found to try them on. The use of medical students as subjects for this kind of research has lately been discussed by Mogey and Watkinson.1 They point out that animal experiments do not take us very far, because animals may tolerate drugs which, in comparable doses, are poisonous to man ; for instance, rabbits can eat with impunity both the death-cap fungus (Antanita phalloides) and the deadly nightshade (Atropa belladonna) in amounts that kill man. Moreover, animals are poor witnesses even compared with the least communicative medical student. Mogey and Watkinson recruited students during lectures, and in their paper they very properly consider the ethical questions. They point out that to approach each student privately might make it embarrassing for him to refuse, whereas general appeals, made to a gathering at a lecture, avoid The volunteers were asked any individual pressure. to tell their parents about the proposal, and those under 21 had to obtain their written consent. Those who volunteered seemed to do so partly to gain first-hand experience of research, partly as a diversion from humdrum existence, and partly from a desire to benefit the community. It is important that this praiseworthy goodwill of medical students should not be exploited and, as the World Medical Association says in its memorandum, " every step must be taken in order to make sure that those who submit themselves to experiThe paramount factor mentation be fully informed. in experimentation on human beings is the responsibility of the research worker, and not the willingness of the On the other person submitting to the experiment." hand, if the use of volunteers is restricted by elaborate rules, inspections, and consent forms, clinical research might be hampered. Experiments on our fellows are, strictly speaking’, forms of vivisection ; but the restrictions applied to animal experiments need not be imposed in the case of healthy human beings who can understand what is happening and can judge for themselves. The important thing is that they should be told exactly what the experiAnd we ments involve and just what the risks are. agree with Dr. Ryle who lately suggested that all reports of experiments on human beings should record that the subjects were volunteers and say how they were enlisted. Concern about such matters was also reflected in a letter from Dr. Dyke,3 in which he said that the Association of Clinical Pathologists’ standing committee on professional affairs and ethics, being anxious to protect human rights, has outlined a procedure to be followed in securing the cooperation of volunteers, with special reference to nurses and medical students. There are other problems raised by the use of healthy medical students. The results may not be the same as in ill patients ; the volunteers are not representative of the general population ; and their knowledge of drug actions and toxic effects may influence experimental results, however carefully controlled. For instance, in observing toxic effects, an educated student on the qui-vive for any untoward sensation is far more likely to notice a side-effect than a patient seeking relief from In assaying the power of analgesics, the a symptom. psychological attitude to artificially produced pain is wholly different from the outlook on pain caused by disease : it is free from the resentment or frustration of organic pain and offset by the curiosity of selfUniv. Leeds med. J. 1. Mogey, G. A., Watkinson, G. 63. 2. Ryle, A. Lancet, 1956, i, 1014. 3. Dyke, S. C. Ibid, July 7, 1956, p. 46.
1956, 5,
385
subject. They now have no further hurdle for eighteen months and often for two and a half years. Then they prepare for the culminating marathon of the finals," which further distorts their understanding by its division into three or more subjects. Few people with experience of students other
at least
THE LONDON:
LANCET
SATURDAY, AUGUST 25, rsss
"
"
Examinations By the Medical Act of 1858 the General Medical was given statutory authority to ensure that registrable medical qualifications carry the knowledge and skill necessary for the efficient conduct of medical practice. A qualifying examination was therefore established as the final test of the candidate’s competence to practise independently (and often in comparative isolation); and by the Medical Act of 1888 he had to qualify in three subjects-medicine, surgery, and midwifery. Since that time there have been enormous changes in general and hospital practice ; and the conditions for registration have been changed too, notably by the Medical Act of 1950, which requires twelve months of house appointments under supervision. Yet the general form of the final examination is the same as it was sixty-eight years ago. There are differences in detail between the examinations held by the 27 licensing bodies, but, in all of them, equal importance is still given to the three major
Council
"
"
are now almost exclusively a test Finals of factual knowledge, and are a poor guide to a candidate’s true worth. Even in the practical part of the examination, the time available and the conditions under which it is carried out allow only a cursory assessment of methods of observation and thought. Of the written papers, PICKERINGhas lately spoken severely : they -" allow no choice of
parts.
question, and they seem designed not to test a student’s capacity to discriminate but his capacity to reproduce material learned from the pages of textbooks or the notes of lectures. The kind of question which is still current in the final examinations for university degrees in medicine is a question such as,Describe the symptoms, signs, complications, and treatment of ulcerative colitis.’ What a comment on six years of university education ! The influence exerted on the medical student by his examinations far exceeds any other that he may meet, and this influence directs him to gain factual knowledge. From the age of 11he has lived under the threat of examinations, and as one follows another he usually comes to accept the view that the acquisition of facts is the primary purpose of study. Moreover, the only method of learning of which he has any experience is often that of committing to memory. There is little doubt that many students spend their lives alternately engaging in and resting from frantic outbursts of blind memorisation. For many, the longest period of rest coincides with the first half of their clinical studies. They have by that time passed the 1st M.B., which (unlike their personal qualities as judged by a selection committee) is the essential requirement for entry into medicine. They have also passed the strict filter of the 2nd M.B.: and many of them have shown such devotion to the bare facts of the examination subjects that they can have achieved little understanding of them and none at all of any "
1.
Pickering, G. W.
Brit. med. J. July 21, 1956, p. 115.
I’m sure I’ve failed have not heard such remarks as Medicine because my answer to that question on dehydration was just pure Surgery." Unhappily, this process of fragmentation is evident throughout the whole medical curriculum. Because the entire examination system has remained virtually unchanged, all additions to knowledge, all the fresh alignments of thought and practice, and all the new combinations between medicine and the other sciences have to be presented to the student in the same old watertight compartments created by the examinations of long ago. The 2nd M.B., in its present form, confines the study of preclinical sciences and bars their integration with clinical work ; and the qualifying examination as effectively prevents continuity between undergraduate and postgraduate study. There can be little doubt, therefore, that our present examinations exert an influence on medical education as unsound as it is powerful. It is unsound because it leads the student to learn facts in isolated blocksand by the worst methods. As LANDELLS puts it,2Z our examinations misdirect the student’s effort because they demand so many parlour-tricks. Their influence is powerful because they are almost the only method of assessment, and therefore upon them depends the chance to enter and stay in a medical school. Financial aid is very often given largely on examination results, and this puts an added emphasis on the examination as the paramount incentive in the minds of the many grant-aided students. The absence of other methods of assessment, and particularly of close personal observation of the individual student by his teachers, ensures the dominance of the examination system over student and curriculum and thereby is partly responsible for the unhealthy effects of that dominance. Improvement in the actual examinations and better timing of them cannot alone put matters right, but until these things have been done there will be little chance of any other improvement. This is the point at which the vicious circle of too many students seeking too much of an ever-increasing amount of factual knowledge must be broken. One of the main reasons why the system, and particularly the qualifying examination, has never been changed is that many people have regarded it as a reasonably accurate form of assessment. Overthe past few years, however, the evidence of its inaccuracy has mounted, and in this issue Professor BULL adds to it by describing the results of his carefulinvestigation of the final examination in medicine at the Queen’s University of Belfast. His findings show clearly that " there is a considerable element of error in the marking of long essay questions, but this error diminishes progressively as the questions are shorttened." Such inquiries are valuable because they provide conclusive objective evidence for what has been obvious for a long time-namely, that there is a large element of chance in these examinations. The best students sometimes fail, and (what is more dangerous) the worst students sometimes pass. It is 2.
Landells, J. W.
Lancet, Aug. 4, 1956, p. 246.
386 its inaccuracy as a method of assessment, coupled with the premium it puts on factual knowledge, that makes the final examination such an unreliable way of maintaining standards. The General Medical Council’s view, put to the Goodenough committee,3 was that the standard of professional practice essential for the safety of the public " depends much more on the efficiency of clinical and other teaching in medical schools than on any control which the Council can exercise by inspecting qualifying examinations." On the other hand, LANDELLS remarks2 that present-day examinations make no use of a splendid opportunity to investigate the teaching which is being given : " they may be an examination of the students but they are not, as they should be, an examination of his teachers." The ability of the final examination to maintain standards is reflected in what happens to those who fail. Every year, despite the recent fall in the failure-rate in the London M.B., hundreds of medical students fail their finals. The vast majority of them pass six or twelve months later. In this period by which their education is extended, it is unlikely that much is done to increase the safeguards for the public. After failure, many students widen their clinical experience hardly at all and engage in more frantic memorisation. Some turn to the crammer, whose successes are based on intensive drilling in examination technique-a bitter mock of the examination and the whole system of medical education. In fact, the experience of the extra six months often lowers the student’s standards and his morale ; and this delay in qualification certainly proves baffling and expensive to the authoritythat is helping to pay his way. Thus, failure in the final examination seems to do little to ensure the qualification of a better doctor six months or so later ; but perhaps this is offset by the fact that students actually learn as the result of It is true that some do so, but in examinations. fouAo6n medical schools students still face external final examinations, and those who fail are as a rule completely in the dark about why. There is no objective evidence that external examinations make for more accurate testing and it is hard to believe that they help to maintain a uniform standard. If they do, then logically the sooner a national external qualifying examination is instituted the better. Meanwhile, failure-rates of up to 50% continue in some external finals : those who fail do not know why ; the examiners know very little of the candidates’ records of work ; and the teachers are deprived of the help which this assessment of their students could give. A corollary to the high failure-rate is that many students take, as an insurance, the Conjoint diploma, piece by piece, during their last clinical year. ELLIS4 has latelv condemned this course, because it " not only adds to the financial strain, but also interferes seriously with the third year of clinical training ; for the idea that students take these extra examinations merely for practice, without specific preparation and without undue concern, is, in my experience, largely a myth. There is no more lamentable facet of medical education in this country than the double external qualifying examination." 3. Report of Interdepartmental Committee H.M. Stationery Office, 1944. 4. Ellis, J. R. Lancet, 1956, i, 816.
on
Medical Schools.
We
few reasons, therefore, for retaining the examination system. Fortunately it should
can see
present
not be hard to
provide a better one. Changes must be directed along two lines. Firstly, the whole system must be closely integrated to the student’s developing knowledge and practical ability during his training. Only thus can the examination be the servant of education rather than its master ; and to be really effective the results of all the earlier examinations should be discussed with each student. So far as clinical work is concerned, the final examination should be one in the general principles of clinical medicine, but there should also be special tests in the essentials of diagnosis and the management of emergencies in medicine, surgery, and obstetrics, which could best be taken at the end of each relevant period of clinical work. Secondly, the examinations themselves should be made more accurate as a measure of a student’s attainments. Professor BULL recommends that more use should be made of the multiple-choice technique of examining, which eliminates marking error." This form of paper has been much used in the United States,5where it has proved effective as a means of comparing the knowledge acquired by students of different schools, and therefore, as a means of maintaining standards of knowledge. It is, of course, a method applicable to fact rather than to powers of discrimination, for which other tests must be applied. As Professor BULL says, it should not be opposed on the grounds that it " will cause the students to lose what little ability they have to write English." The hurried answers to the present essay-type questions can hardly be considered as serious practice in writing English prose. LANDELLS has suggested that a brief viva will divide those who are clearly competent from those who are doubtful, and that this lesser group could then sit a longer written examination. Changes like these, combined with better coördination of examinations and studies, would make things less exacting for both student and examiner and should give a more accurate picture of a student’s capacity to learn, while retaining the value of examinations as an incentive to work. They will not, however, give much idea of the candidate’s powers of observation and thought. These can be effectively measured only by close observation of the student at work - ideally, when practising under supervision with some responsibility. No such opportunity now arises except during the preregistration year, after the final examination, so that a big change in the present curriculums is necessary-and many would add urgently so.6 The recent pleas for elasticity in the curriculum made by the Royal College of Physicians and others are peculiarly relevant. PICKERING1 has said that " any attempt at defining a medical undergraduate course "
is
a compromise, and a purely arbitrary There are many ways to Rome. We shall never find out the best way so long as all pilgrims are forced to take the same path." The curriculum must be relaxed before other paths can be tried. Standards could be as effectively maintained as they are at present if the General Medical Council were to adopt the suggestion of control by inspection of medical schools, and if the " Council’s inspection of a medical
necessarily
one.
Sinclair, D. C. Ibid, 1953, ii, 947. 6. See Ibid, 1955, ii, 425 ; and also proposals of the Royal College of Physicians of London, Ibid, 1956, i, 437. 5.
387
school’s examinations should henceforward be part of their inspection of the medical school itself." 7 In this way a school could make full use of progressive assessment by the teacher’s own observations, which is now successfully used in the best American universities--often with very little in the way of supplementary examinations. It is notable that, under these conditions, students work harder as well as more profitably ; for the weaker incentive from fear of examinations is more than balanced by the stronger spur from increased interest in their work. It must be borne in mind that some American schools have demonstrated the unfortunate results of relying on innumerable tests. This is important because the impression has grown up in this country that the examination is the only assessment and the only incentive : Examinations are the only effective way to make the average student take a subject seriously."8 There can be but poor training while such views dictate policy. When we have got beyond this outlook, education in its true sense should be possible, and it may even be that the final examination could include an honours paper, with a choice of questions enabling the candidate to show his powers of reasoning and discrimination. Meanwhile, we must remember that the results of our present system can be little improved even by the most enlightened examiners. So long as there is no limit to the factual knowledge covered by the examination, the strongest impetus in medical education will not bewhat the examiners know they are seeking but what the students believe the examiners are seeking. "
Annotations MEDICAL ETHICS EXPLAINED IN this country, contrary to popular belief, only a minority of doctors have taken the Hippocratic Oath or have given any similar pledge. But, especially abroad, many universities now ask for an explicit affirmation ; and at Witwatersrand, for example, medical students entering their second year must subscribe to a declaration of professional secrecy. The student (or his senior) who wants a guide to medical ethics could not do better than read the small book in which Prof. G. A. Elliott of that university and recently set out the ethical codes of the world, explained how they apply in everyday work.99 His guide to medical ethics has, as he says, a South African flavour ; but its subject is universal, and so is the wisdom he offers. Effectively, he makes once more the fundamental point that the main purpose of ethics is to ensure the patient’s welfare (regardless of the doctor’s convenience), and that the patient’s welfare demands the right relationship not only between doctor and patient but also between doctor and doctor. " A doctor ought to behave to his colleagues as he would have them behave to him," says the International Code of Medical Ethics, and so should a student. Professor Elliott’s own philosophy is illustrated by his concluding remark that, even though we may fall far short of our ideal of service, "to act in accordance with the traditional ethics of medical practice is its own reward." 7. A Report of Medical Teaching Committee of the Royal College of Physicians of London. See Lancet, 1955, ii, 132. 8. Curran, D. Brit. med. J. 1955, ii, 515. 9. Medical Ethics. By G. A. ELLIOTT, professor of medicine in the University of Witwatersrand. Johannesburg : Witwatersrand University Press. 1954. Pp. 55.
EXPERIMENTS ON STUDENTS THE big advances in chemical pharmacology and the enthusiasm for new antibiotics mean that more and more drugs have to be tried and more and more human beings have to be found to try them on. The use of medical students as subjects for this kind of research has lately been discussed by Mogey and Watkinson.1 They point out that animal experiments do not take us very far, because animals may tolerate drugs which, in comparable doses, are poisonous to man ; for instance, rabbits can eat with impunity both the death-cap fungus (Antanita phalloides) and the deadly nightshade (Atropa belladonna) in amounts that kill man. Moreover, animals are poor witnesses even compared with the least communicative medical student. Mogey and Watkinson recruited students during lectures, and in their paper they very properly consider the ethical questions. They point out that to approach each student privately might make it embarrassing for him to refuse, whereas general appeals, made to a gathering at a lecture, avoid The volunteers were asked any individual pressure. to tell their parents about the proposal, and those under 21 had to obtain their written consent. Those who volunteered seemed to do so partly to gain first-hand experience of research, partly as a diversion from humdrum existence, and partly from a desire to benefit the community. It is important that this praiseworthy goodwill of medical students should not be exploited and, as the World Medical Association says in its memorandum, " every step must be taken in order to make sure that those who submit themselves to experiThe paramount factor mentation be fully informed. in experimentation on human beings is the responsibility of the research worker, and not the willingness of the On the other person submitting to the experiment." hand, if the use of volunteers is restricted by elaborate rules, inspections, and consent forms, clinical research might be hampered. Experiments on our fellows are, strictly speaking’, forms of vivisection ; but the restrictions applied to animal experiments need not be imposed in the case of healthy human beings who can understand what is happening and can judge for themselves. The important thing is that they should be told exactly what the experiAnd we ments involve and just what the risks are. agree with Dr. Ryle who lately suggested that all reports of experiments on human beings should record that the subjects were volunteers and say how they were enlisted. Concern about such matters was also reflected in a letter from Dr. Dyke,3 in which he said that the Association of Clinical Pathologists’ standing committee on professional affairs and ethics, being anxious to protect human rights, has outlined a procedure to be followed in securing the cooperation of volunteers, with special reference to nurses and medical students. There are other problems raised by the use of healthy medical students. The results may not be the same as in ill patients ; the volunteers are not representative of the general population ; and their knowledge of drug actions and toxic effects may influence experimental results, however carefully controlled. For instance, in observing toxic effects, an educated student on the qui-vive for any untoward sensation is far more likely to notice a side-effect than a patient seeking relief from In assaying the power of analgesics, the a symptom. psychological attitude to artificially produced pain is wholly different from the outlook on pain caused by disease : it is free from the resentment or frustration of organic pain and offset by the curiosity of selfUniv. Leeds med. J. 1. Mogey, G. A., Watkinson, G. 63. 2. Ryle, A. Lancet, 1956, i, 1014. 3. Dyke, S. C. Ibid, July 7, 1956, p. 46.
1956, 5,